Abstract
In the UK, most adults with hypertension are managed in Primary Care. Referrals to Secondary Care Hypertension Specialists are targeted to patients in whom further investigations are likely to change management decisions. In this position statement the British and Irish Hypertension Society provide clinicians with a framework for referring patients to Hypertension Specialists. Additional therapeutic advice is provided to optimise patient management whilst awaiting specialist review. Our aim is to ensure that referral criteria to Hypertension Specialists are consistent across the UK and Ireland to ensure equitable access for all patients.
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Introduction
In the UK, most adults with hypertension are managed in Primary Care. National and international guidelines advise that adult referrals to Secondary Care Hypertension Specialists are targeted at patients in whom further investigations are likely to change management decisions [1,2,3,4,5,6]. Referrals are recommended when patients have raised blood pressure with life threatening target-organ damage (i.e. emergency/same day referrals); or when patients have, for example, suspected secondary hypertension, resistant hypertension, or complex polypharmacy (i.e. routine referrals) [1,2,3,4,5,6].
In this statement, the British and Irish Hypertension Society (BIHS) summarise their recommendations for adult emergency and routine referrals to Secondary Care Hypertension Specialists and highlight where this advice is supported by the National Institute for Health and Care Excellence (NICE) and/or International Societies (Tables 1 and 2) [1,2,3,4,5,6]. Table 3 summarises the ideal information to accompany referrals to facilitate communication between Primary and Secondary Care services. Where there are long waiting times to access routine Secondary Care hypertension services, the BIHS offer additional therapeutic advice to optimise patient management whilst awaiting specialist review (Fig. 1). Finally, the challenges facing referrers in identifying a Hypertension Specialist in the UK are discussed.
Adult referral criteria to a secondary care hypertension specialist
The clinical situations where the BIHS recommends emergency/same day referrals are outlined in Table 1.
The clinical situations where the BIHS recommends routine referrals are outlined in Table 2.
Prior to making routine referrals, clinicians should have:
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1.
Confirmed hypertension is present by either Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM).
AND if applicable,
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2.
Followed NICE guidelines NG136 on hypertension management [1], Fig. 1.
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3.
Assessed concordance with medication (preferably by urine testing, where available [7]).
Information to share with hypertension specialists
To facilitate communication between referrers and Hypertension Specialists, the BIHS recommends that, where possible, the information in Table 3 is included with the referral. This avoids patients undergoing repeated testing unnecessarily, maximises the efficient use of resources and enables patients to start new, or modified, treatment regimens as soon as possible.
Management advice for routine referrals awaiting hypertension specialist review
The BIHS acknowledges that current waiting times for routine NHS referrals may be considerable. To optimise hypertension treatment whilst patients await specialist review, clinicians may wish to consider the following steps:
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For newly diagnosed patients in whom secondary causes are suspected, or aged <40 years at diagnosis, or post-partum, a non renin-angiotensin-aldosterone system interfering drug is preferred (e.g. amlodipine or equivalent) as a temporary treatment while awaiting specialist review. This will facilitate interpretation of screening tests for the secondary causes of hypertension. Definitive long-term therapy should follow the guidance in Fig. 1.
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For those with established and uncontrolled hypertension, having tried multiple drug therapies, additional therapeutic options are summarised in Fig. 1. The choice of exemplar drugs within each class was based on the totality of evidence for each drug in reducing morbidity and mortality combined with duration of action. Long acting drugs are strongly preferred to minimise the impact of a missed dose and reduce blood pressure variability.
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Clinicians may also find patients are willing to revisit lifestyle modifications, including optimising weight, salt and alcohol intake and review their medication concordance whilst awaiting specialist advice. Re-assessing white coat hypertension by ABPM or HBPM can also be helpful [8].
Selection of a hypertension specialist
It is important to refer patients to Hypertension Specialists who have appropriate training, experience and interest in hypertension management and who have access to specialist facilities to conduct relevant investigations. In the UK, there is currently no specialist registration for hypertension doctors and the only medical training curriculum that includes a specific module in hypertension is Clinical Pharmacology and Therapeutics. The BIHS is currently working on a system for accreditation and recognition of specialist hypertension services in the UK. In the interim, referrers can check if their local Hypertension Specialist is a member of the British and Irish Hypertension Society (Email: bihs@in-conference.org.uk), holds a European Hypertension Specialist certificate (https://www.eshonline.org/communities/hypertension-specialist/directory-of-specialists/) or works at a European Hypertension Centre of Excellence (https://www.eshonline.org/communities/excellence-centres/).
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Acknowledgements
We would like to thank the following members of the BIHS Guideline Standing Committee for their expert review of this manuscript: Professor Adrian J.B. Brady, Dr Andrew Jordan, Dr Spoorthy Kulkarni, Professor Peter Sever and Dr Wayne Sunman. We also thank the BIHS Executive Committee for their expert review and approval of the final draft of the manuscript: Professor Philip Chowienczyk, Dr Pankaj Gupta, Dr Sinéad McDonagh, Mr Sam Olden, Dr James Sheppard and Dr Pauline Swift. We confirm that all authors were excluded from the BIHS Peer Review and Approval process.
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PL, JG, VK, SP and IBW wrote the initial draft. PL proposed the first version of Fig. 1 that was subsequently developed by JG, IBW and NRP. All authors critically appraised the manuscript while providing expert input and contributing to the formulation of position statements and therapeutic advice. All authors reviewed the final draft.
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Professor Adrian J.B. Brady has received honoraria from Daiichi-Sankyo, Amgen, Sanofi-Aventis, Bayer, MSD, and Novartis. Professor Phil Chowienczyk has an interest in Centron Diagnostics, a company that has produced technology for blood pressure measurement. Professor Jacob George has received consultation fees as a member of the scientific advisory board of Novartis and funding for conference attendances from Daiichi-Sankyo. Dr Pankaj Gupta has received research grants, lecture honoraria and funding for conference attendance from Sanofi-Aventis and Amgen, and consulting fees from Ionis Pharmaceuticals. Professor Terry McCormack has received lecture honoraria and/or consultation fees from Amarin, AstraZeneca, Bayer, Daichi-Sankyo, Medtronic, Novartis, OMRON and Sanofi-Aventis. Dr Sinéad McDonagh is currently funded by an NIHR School for Primary Care Research Postdoctoral Fellowship. Professor Neil R Poulter has received lecture honoraria and/or consultation fees from several pharmaceutical companies that manufacture blood pressure lowering agents including AstraZeneca, Eva Pharma, Lri Therapharma, Napi, Pfizer, Servier and Sanofi-Aventis. Dr Pauline Swift has received lecture honoraria from Astra-Zenica, Boehringer-Ingelheim and Bayer. Professor Ian B Wilkinson has received research grants from AstraZeneca, GSK and scientific advisory board consultation fees for Viatris. LF, JG, AJ, VK, SK, PL, PS, JS, WS, SO, and SP have no competing interest to declare for this manuscript.
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Lewis, P., George, J., Kapil, V. et al. Adult hypertension referral pathway and therapeutic management: British and Irish Hypertension Society position statement. J Hum Hypertens 38, 3–7 (2024). https://doi.org/10.1038/s41371-023-00882-2
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DOI: https://doi.org/10.1038/s41371-023-00882-2